Successful Breastfeeding What You Need to Know SECOND TRIMESTER

The Birth Center Neonatal ICU Pediatrics 1 Breastfeeding The experience of breastfeeding is special for so many reasons. As you make the decision on how to feed your baby, remember you are designed to provide the best nutrition for your baby.

Dear New Parent,

As you look forward to the arrival of your new little one, we would like to offer you this booklet to give you the information you will need to make important decisions regarding feeding your baby. We are striving to give you consistent messages from your OB doctor/midwife, the nurses and staff at the hospital, to your baby’s doctor. Our job is to help you meet your breastfeeding goals for you and your baby. Keep in mind that breastfeeding is a learned skill; it requires patience and practice. Gaining knowledge early on will help you be more successful when the time comes to feed your baby. We look forward to taking care of you and your baby.

The Birth Center Neonatal ICU Pediatrics

2 You are special because you can make the food that is uniquely perfect for your baby. Invest the time in yourself and your baby—for your health and for the bond that will last a lifetime.

There are many benefits to breastfeeding for both you and your baby. Your whole family benefits as well. Breastfeeding is recommended as the ideal nutrition for newborns by: American Academy of Pediatrics, the American Academy of Family Practice Physicians, the American College of Obstetrics and Gynecologists, the World Health Organization and UNICEF. These organizations recommend that babies are exclusively breastfed until solid foods are started around six months of age, and then continue breastfeeding until the baby is at least one year of age or longer, if mom and baby desire. Any amount of breastfeeding is beneficial for your baby.

Most mothers who breastfeed longer than several months find they are able to regain their figure easier and maintain their ideal weight. You do not have to follow any special diet to breastfeed. In fact, the more variety you have in your diet, the more likely your baby will accept those foods later on. Your breastmilk contains hundreds of nutrients, hormones and antibodies that cannot be artificially manufactured. Your milk changes to meet your baby’s growth needs.

Breastfeeding can fit into any lifestyle. We can teach you how to breastfeed as a working mother, how to have an active life, handle public modesty and how to involve your whole family in parenting.

Breastfeeding education

■■ Sign up for Childbirth Education classes that include breastfeeding at valleymed.org/birthclass.

■■ Make a prenatal appointment with UW| VMC Lactation Services at 425.228.3440, ext 2526.

3 How Can Dad, Partner, Family and Friends Help?

Breastfeeding becomes a lifestyle, not just a way to feed your baby. Dads, partners, family members and friends can be involved in the breastfeeding experience too.

Fathers, partners, family members and friends can:

■■ Support the breastfeeding relationship by being kind and encouraging— encouraging words go a long way, especially in those first days and weeks.

■■ Offer support and love during this time because mom will be putting lots of work into breastfeeding.

■■ Be a good listener when mom needs to talk through breastfeeding concerns.

■■ Make sure mom has enough to drink and gets enough rest.

■■ Help around the house and take care of other children at home.

■■ Find special ways to offer more than nutrition to the baby—others can give emotional nourishment by spending time with baby.

Fathers, partners, family members and friends can benefit from breastfeeding too. Many people feel love and relaxation just from sitting next to a mother and baby during breastfeeding. There are many ways dads, partners, family members and friends can love and bond with your baby beyond feeding them.

What can dads and partners do?

Dads and partners are an important part of a baby’s life. Just as the bond between mom and baby is important, so is the bond between dads or partners and a baby. Skin- to-skin time can be just as special and important. Beyond feeding, dads and partners can hold, comfort, sing to, read to, bathe, play with and cuddle with the baby. Encourage “special time” in many ways besides feeding so that breastfeeding can continue.

4 How You and Your Baby are Preparing Now for Breastfeeding

When do you start making breastmilk? RIGHT NOW! “Breastfeeding is a gift Beginning in the second trimester, women begin making milk. Your body produces hormones that lasts a lifetime.” which prevent an abundance of milk production -Author Unknown during your pregnancy. Once you deliver your baby and your placenta is delivered, your body goes into high gear to make milk for your baby. You may notice now that you are leaking from your breasts or there is a dry substance on your bra at night. If you are not noticing these things happening, do not worry.

You may notice some changes in your breasts as your pregnancy continues:

■■ Breasts grow larger.

■■ Veins become more prominent.

■■ Nipple and areola (darkened skin around your nipple) darkens and/or enlarges.

■■ Montgomery Glands (bumps on the areola) get bigger. These glands excrete oil that prevents drying, cracking and infections while you are breastfeeding.

You do not need to be doing anything to prepare your breasts for breastfeeding at this time. The best thing you can do now is to learn all you can about breastfeeding before your baby arrives.

Your baby is also learning how to feed at this time!

Babies learn how to suck starting around 14 weeks of pregnancy. They practice on their fists and fingers. You may have seen this during your ultrasounds. They also are swallowing amniotic fluid, which prepares them for swallowing breastmilk when they are born.

5 How Breastmilk is Made

Knowing how the breast works to produce milk can help you understand the breastfeeding process. Beyond the changes you can see on the outside of your breasts, it is even more fascinating to know what is going on in the inside. There is an entire glandular system made up of alveoli (which make and Alveoli store milk) and milk ducts (tubes from your alveoli to the nipple). When your baby latches to your breast, your brain is Milk Ducts stimulated to release hormones. Those hormones tell your breasts to release milk from your alveoli into the milk ducts and out through the holes in your nipple. When your breasts become fuller and tender during pregnancy, your alveoli are letting you know they are getting ready to work. Some women may not feel these changes in their breasts. Others may notice these changes after their baby is born.

The alveoli make milk in response to the hormone prolactin. Prolactin rises when the baby suckles at your breast. Another hormone, oxytocin, causes small muscles around the breast to contract and move the milk through the small tubes or milk ducts. This moving of the milk is called the let-down reflex.

Oxytocin also causes the muscles of the uterus to contract during and after birth. This helps the uterus to get back to its original size. It also lessens the bleeding a woman may have after giving birth. The release of both prolactin and oxytocin may be responsible in part for a mother’s intense feeling of needing to be with her baby.

The hormones released during breastfeeding also relax mom. So you may notice feeling more sleepy during a feeding as well.

Coping with pain during labor

Using medication during labor can lead to difficulties with the initiation of breastfeeding. There are many ways to cope with the pain and anxiety associated with childbirth. At Valley Medical Center, we look forward to assisting and supporting you through your labor. The Birth Center at Valley offers Jacuzzi tubs, birthing balls, peanut balls, options to walk around during your labor and a relaxation channel on your television. Other helpful pain management techniques include: breathing exercises, imagery, massage, music, aromatherapy, and different positions like standing or on your hands and knees. Many mothers find that having a support person or doula during labor is helpful. Childbirth classes and a tour of the hospital will educate and help you and your support person be as prepared as possible for your special day.

You can register for classes and free tours at valleymed.org/birthclass.

6 Skin-to-Skin

When your baby is born, be assured that we will do everything we can to protect Benefits for baby: that “Golden Hour” right after birth. This is a special time that is helpful to both you and your baby. Right after delivery, if your baby is well and not needing extra ■■ Regulates temperature care, he/she will be placed directly on your bare chest. This can happen whether ■■ Regulates heart rate, respiratory rate you have a vaginal or caesarean delivery. It is important to allow your baby to stay and blood pressure there for at least the first hour or until the first feeding. Simple tasks, such as ■■ Promotes bonding weighing your baby, can wait until after this special time. Your baby may be ready to eat within 30-60 minutes after delivery. Watch your baby for feeding cues when ■■ Less crying he/she is ready to feed. These cues may be smacking or licking lips, bringing ■■ Breastfeeds better hands to mouth or opening mouth wide. You and your baby benefit greatly during ■■ Promotes brain development this very simple act of skin-to-skin. (See benefits on right.) ■■ Regulates blood sugar Skin-to-skin care with the mother (or any support person), as often as possible in the beginning days and weeks of life, has shown to help moms meet their breastfeeding goals. Some babies will latch on right away, and for others it takes Benefits for mother: more time. Skin-to-skin is one way to encourage your baby to latch. ■■ Promotes bonding Feed your baby as soon as possible after birth. This is the best time for your ■■ Builds confidence to care for baby baby’s first feeding. The baby will be in a quiet, alert state for the first one to two ■■ Decreases engorgement in the first hours of life. The sucking reflexes peak in the first few hours of life and your “milk- few days after birth making” hormones are very high at this time. Protect this “Golden Hour!” ■■ Learn baby’s feeding cues

■■ Increases milk supply

■■ Reduces risk of postpartum depression

■■ More sleep

Protect and cherish the “Golden Hour” right after birth!

7 Hand Expression

Hand expression is massaging the breast with your hands to release your milk. It is our goal that every mother knows how to hand express her milk prior to leaving the hospital. Massaging your breasts and hand expressing your milk prior to feedings will help establish your milk supply in those beginning days. Prior to feedings, hand massage and expression will also get your milk ready for when your baby latches.

Why should I hand express How do I hand express my milk? my breastmilk? 1. Sit upright and lean forward slightly.

■■ Breast massage and hand expression allow your baby to get 2. Massage your breasts starting at the armpit working more of your milk during a feeding. toward the nipple. Press firmly toward your chest wall in ■■ Breast massage and hand expression help stimulate small circular motions. and empty the breasts which will help increase milk supply. 3. Place thumb and first two fingers on the breasts about ■■ Breast massage and hand expression are important for 1 to 1 1/2 inches behind the areola (darkened area of sleepy babies or babies not latching properly by allowing the your breast). Position your fingers like a “C.” mom to express milk into a spoon, syringe or cup to feed baby in the beginning hours and days. 4. Keep your thumb and fingers in line with your nipple. Do not cup your nipple. ■■ The first few days after birth, breast massage and hand expression are much more effective than a breast pump in 5. Gently press back towards your chest. For large breasts, collecting colostrum (the first milk you have in the beginning lift up before pushing back toward your chest. days after birth). 6. Roll thumb forward toward the nipple, moving finger pressure from the middle finger to index finger as you When should I hand express roll your thumb. my breastmilk? 7. Pause. ■■ Express colostrum within the first hour after delivery. 8. Repeat in rhythmic pattern (press, compress, release), ■■ Massage and express the breasts before each feeding. moving your hand around the breast to empty all your ■■ Express breastmilk if you have a sleepy baby who is milk ducts. not latching well or if you have a baby who is not latching properly.

8 Learning to Breastfeed

Feeding cues Getting comfortable

Your baby will show you signs when he/she is hungry. These Make sure you have gone to the are called feeding cues. Your baby will be rooming in with you bathroom, have a drink of water during your stay at the hospital which helps you learn your and/or snack and get comfortable. baby’s feeding cues. Gather pillows to place behind your back, neck, arms or elbows. Position Feeding cues are: yourself so that the baby is brought ■■ Eyes moving under the eyelids to you, instead of you going to your baby—your back will thank you. ■■ Stirring or restless movement

■■ Mouth opening

■■ Turning head

■■ Moving hand to mouth

When you start noticing these cues, your baby is saying, “Mom, I am hungry!” Crying is a late cue. Once you start noticing these early feeding cues, it is time to get ready to feed.

Preparing your baby

Help your baby wake before feeding. As the baby starts showing feeding cues, you can unswaddle, change a diaper and undress baby so that he/she can be skin-to-skin with you. It is difficult to get a proper latch and position if your baby is swaddled in blankets.

9 Breastfeeding Holds

It is important for your baby to be properly positioned when feeding. Make sure your baby’s whole body is turned so the tummy is toward you. Keeping your baby’s head and body in a straight line will help with latching properly. Whatever position you choose, make sure you are comfortable. You can use pillows under your arms, elbows, neck or back to give you added comfort and support. Keep in mind that what works well for one feeding may not work well for the next. Keep trying different positions until you are comfortable.

Cross-cradle Football hold hold

In this position, you Baby is “wrapped” support the baby’s back around your side, belly and neck with the hand to ribcage, with his/her and forearm opposite of nose at the level of the the breast you are nipple. Support his/her using, while your other body and legs with the hand supports the forearm closest to the breast from the outside. breast you are using. Tuck your baby under Use the palm and your opposite breast to fingers of the same arm ensure a close hold. This position gives a mom more control of to support the baby’s upper back and neck. This is an easy her baby and her breast when breastfeeding. This position is hold so that you can see what you are doing or to take the often easier for newborns. pressure off your abdomen if you have a C-section.

Cradle Side-lying hold position

Baby’s whole body is In this position, you and facing you across your your baby are facing chest, with his/her head each other lying on your nestled on the upper sides with baby’s body part of your forearm cuddled close to yours. next to your elbow. Your You may need a small baby should be “belly- burp cloth or washcloth to-belly” with you. This under the baby’s head will help ensure your to bring it to the breast baby’s whole body is in level. A pillow between a straight line to help with swallowing. Hold your breast with your legs may make lying on your side more comfortable. the opposite hand from the inside.

10 Proper Latch and Breastfeeding

Getting a proper latch is one of the most important things you can do to ensure that your baby will get the milk he/she needs for growth and development. Below is a list to help ensure a proper latch.

1. Sit or lie down in a comfortable position, as upright as possible. Use pillows for support under your arms and under your baby. You may need to remove your gown in the hospital so that fabric does not prevent you from seeing your baby’s face as she latches onto the breast. Support your feet with a footstool or place them flat on the floor when sitting in a chair.

2. To encourage your milk to “let down,” massage your breast from under your armpits to your areola (the dark circle behind your nipple).

3. Roll out your nipple between your thumb and index finger.

4. Hand express some colostrum (your first milk) onto your nipple. (See page 8.)

5. Support your breast in a C-hold when you offer it to your baby. If possible, continue this support hold throughout the first week of feeding to give your baby time to learn how to pace her breathing and swallowing, without also having to support the weight of your breast.

6. Try different feeding positions. Rotating positions helps decrease nipple tenderness and promote milk extraction.

1 2 3

7. Tickle your baby’s lips with your nipple until he/she opens his/her mouth wide like a yawn. Some babies will open best by stroking the upper lip and others open better with a downward stroke. Be patient. Remember, babies don’t have to open their mouths very wide to suck on their fingers while in the womb. Positioning your baby’s nose at your nipple will help get a wide mouth as well. (See 1 picture above.)

8. When the baby’s mouth is wide open, pull him/her to your breast with a quick motion leading with the chin, then the upper jaw. The nipple should be pointed towards his/her upper lip/nose so he/she grasps a little more of the lower areola than the upper area. (See picture 2 above.) This is called an asymmetrical latch. The chin should be pushed into the bottom of the breast. Baby’s nose may touch the upper areola with an adequate space between the flared nostrils and breast for breathing. (See picture 3 above.) You do not need to create an “air pocket” for the baby by pushing down on your breast with your fingers. This pushing with your fingers can block the milk from moving down through your milk ducts.

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11 Proper Latch and Breastfeeding (continued)

Deep Latch

Nipple Tongue

9. If your baby is latched on the breast properly, you should see his/her lips flanged over the areola, with tongue over the lower gums. Babies’ temples and ears wiggle when jaws move front-to-back with a suck-pause-close pattern as they swallow. If you listen closely, you will hear a soft swallowing sound that becomes more audible and frequent as your milk supply increases. Some tenderness of your nipple is normal when the baby first latches, but it should feel like a gentle “tug” within 15 – 20 seconds. You may also feel some cramping of your uterus while your baby feeds.

10. Offer both breasts at each feeding, but make sure your baby is finished with the first side before offering the second. A baby should let go of the nipple when finished nursing. If the baby is sleepy, you may need to do some massage and compression of the milk behind the areola to help increase the flow. Babies do not always want both sides at one feeding or they may eat on both sides two or three times in the same feeding session. Feed your baby until he/she looks satisfied, not based on the clock.

11. If your baby doesn’t end the feeding by releasing your nipple, put your finger in the corner of his/her mouth and break the suction. Remove the baby completely before you remove your finger.

12. Do not limit the time your baby stays on your breast. It can take your milk 7 – 10 minutes to let down during the first feedings. If your baby is latched on properly, this will not increase nipple tenderness. Immediately after your baby is finished, your nipple should look rounded, but more elongated than at rest. You shouldn’t see a red pressure stripe across the end of the nipple or the bottom sloped like a new lipstick tube.

13. After your baby is done nursing, express a few drops of milk on your nipple; rub it in and let it air dry. This will help with any nipple tenderness. If you need additional comfort measures and you are sure the baby is latching on properly, you may also use a small amount of 100% purified lanolin on each nipple after feedings. Contact a lactation consultant if the tenderness lasts more than the first week.

14. Babies are very sleepy during the first couple of days after birth. Unbundling your baby, changing his/her diaper, or talking and playing with him/her may help to awaken your baby. Try to burp your baby between breasts to wake him/her for the rest of the feeding. During the feeding, you may try to stimulate his/her jaw and chin area with your index finger, massage your breasts, or stimulate your baby’s back with your supporting hand to keep him/her awake as long as possible.

12 How Do I Know if My Baby is Getting Enough to Eat?

Signs your baby is getting enough milk and is satisfied:

■■ Baby may fall asleep after a feeding.

■■ Baby will come off breast by himself or push nipple out of his mouth.

■■ Baby is calm and alert.

■■ Baby’s hands and body are relaxed.

■■ Baby is giving adequate amount of wet and dirty diapers (see chart).

■■ Baby’s stool has transitioned to mustard yellow by day 5.

■■ Weight gain: Your baby should begin gaining weight by day 4 and be back to birth weight by 2 weeks of age.

Baby’s Feeding Wet Diapers Stool Color of stool Age Frequency (minimum) (minimum)

On Cue Day 1 1 1 – 2 Greenish-black tarry meconium (8 – 12 times per 24 hours)

On Cue Day 2 2 2 – 3 Greenish-black tarry meconium (8 – 12 times per 24 hours)

On Cue Day 3 3 2 – 3 Brown/green (8 – 12 times per 24 hours)

On Cue Day 4 4 2 – 3 Brown/yellow (8 – 12 times per 24 hours)

On Cue Day 5 5 4+ Yellow (8 – 12 times per 24 hours)

On Cue Day 6 6 4+ Yellow seedy (almost like mustard) (8 – 12 times per 24 hours)

On Cue Yellow-seedy (some babies switch to less Day 7+ 6 – 8 4+ (8 – 12 times per 24 hours) frequent, but large, bowel movements)

13 Exclusive Breastfeeding

You will be encouraged to exclusively breastfeed while you are in the hospital. Exclusive breastfeeding means your baby is receiving your breastmilk and nothing else. Your baby will not be given formula, water or a pacifier, unless it is needed for a medical reason.

Exclusive breastfeeding for the first 4 – 6 weeks is very important for getting your milk supply started. Breastfeeding during these early weeks “sets” your milk supply. When your baby sucks on your breasts, your body learns to make just the right amount of milk your baby needs to grow.

Using formula in the early weeks may set your milk supply lower than your baby needs. If you set your milk supply high in the first 6 weeks, you will find it easier to maintain your milk supply for the rest of your baby’s first year and beyond.

Avoid using pacifiers or any artificial nipples for the first month of life. Babies who use a pacifier do not breastfeed as often. Offer your breast as your baby shows early signs of hunger or feeding cues. This will help ensure an early establishment of your milk supply. Your baby should be feeding at least 8 – 12 times per 24 hours, including at night. Your milk increases by supply and demand. The more your baby feeds and empties your breasts, the more milk you will make to meet his/her needs. Pacifier use can reduce the amount of breastfeeding while you and your baby are learning to breastfeed. This may cause decreased milk production. To ensure a good milk supply and a baby who latches well, do not offer a bottle to your baby until 4 – 6 weeks after birth.

If your baby is fussy, always offer your breast first. You may also place your baby skin-to-skin to help calm him/her. This simple act gives so many benefits to both you and your baby. You, dad, partner, or any support person may also place a clean finger with fat pad faced up and nail down into your baby’s mouth to calm as well. This will act as a more natural type of pacifier. Offering your finger will allow your baby to cup the tongue around the finger, which is what occurs during breastfeeding.

Remember these beginning days are a learning process for both you and your baby.

14 Breastfeeding and Returning to Work

Planning ahead for your return to work can help ease the transition. Learn as much as you can before the baby’s birth and talk with your employer about your options. Planning ahead can help you continue to enjoy breastfeeding your baby long after your maternity leave is over. Check with your insurance about purchasing a breast pump prior to having your baby. You can also discuss this with your Women, Infants and Children (WIC) office.

What you can do during your pregnancy to prepare for breastfeeding after returning to work:

■■ Take a breastfeeding class or make an appointment with Valley’s Lactation Services to discuss working and continue to breastfeed.

■■ Talk with your boss about your plans to breastfeed.

■■ Find out if your company offers a lactation support program. Look for areas to pump while at work. There are many businesses that offer a lactation room or area for you to pump.

■■ Talk to other women who have pumped after returning to work.

■■ Explore childcare options. When a childcare facility is close to your work, you can visit and breastfeed your baby during lunch or other breaks. Make sure the facility will feed your baby with your pumped breastmilk.

■■ Find resources for pumping and storing your breastmilk.

Valley Medical Center US Department of Health Breastfeeding valleymed.org and Human Services: Resources Lactation Services Office of Women’s Health 425.228.3440 ext 2526 womenshealth.gov/breastfeeding

WIC (Women, Infants and Children) University of Washington Medical Center doh.wa.gov/YouandYourFamily/WIC.aspx healthonline.washington.edu (search breastfeeding) La Leche League lalecheleague.org Centers of Disease Control and lllofwa.org Prevention-Breastfeeding cdc.gov/breastfeeding National Breastfeeding Line 1.800.994.9662 Breastfeeding Online Jack Newman, MD

Baby Friendly Hospital Initiative breastfeedingonline.com babyfriendlyusa.org Kelly Mom

World Health Organization kellymom.com who.int/topics/breastfeeding.en (search breastfeeding)

15 The Birth Center Neonatal ICU Pediatrics

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